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Symptom Survey

If you want to learn more information about food sensitivity testing, fill out the symptom survey below. Within 72 hours, Lily will contact you to schedule a complimentary 20 min phone consult where we’ll review the results, assess whether food sensitivities may be playing a role in your condition, and see if you qualify to become a client.

If you are a current client, rate your symptoms per your experience since your most recent nutrition consult.

Name

Email

Phone Number

Height

Current Weight

Chief Complaints

In order to make an accurate assessment, please fill in the following form completely. Score every symptom based on your experience over the last 30 days, or since your last Symptom Survey, whichever was most recent. Using the SCALE OF SYMPTOM POINTS listed below, FILL IN the appropriate score in the corresponding field for EVERY symptom listed.

SCALE OF SYMPTOM POINTS:
0 = Rarely or Never experience this symptom
˜1 = Infrequently experience this symptom (1 time or less per week)
˜2 = Occasionally experience this symptom (2 or more times per week)
˜3 = Frequently experience this symptom (3 or more times per week)
˜4 = Constantly experience this symptom (almost daily)

CONSTITUTIONAL
01234 Fatigue (sluggish, tired)
01234 Hyperactive (nervous energy)
01234 Restless (can’t relax/sit still)
01234 Sleepiness During Day
01234 Insomnia at Night
01234 Malaise (Feeling Lousy)

EMOTIONAL/MENTAL
01234 Depression
01234 Anxiety
01234 Mood Swings
01234 Irritability
01234 Forgetfulness
01234 Lack of concentration/focus

HEAD/EARS
01234 Migraine (any kind)
01234 Headache (other than Migraine)
01234 Earache
01234 Ear Infection
01234 Ringing in Ear
01234 Itchy Ears
01234 Discharge From Ears

SKIN
01234 Blemishes, Acne
01234 Rashes, Hives
01234 Eczema
01234 “Rosy” Cheeks

NASAL/SINUS
01234 Post Nasal Drip
01234 Sinus Pain
01234 Runny Nose
01234 Stuffy Nose
01234 Sneezing

MOUTH/THROAT
01234 Sore Throat
01234 Swollen Throat
01234 Swelling of Lips/Tongue
01234 Gagging/Throat Clearing
01234 Canker Sores

LUNGS
01234 Wheezing
01234 Chest Congestion
01234 Dry Cough
01234 Wet Cough

EYES
01234 Red or Swollen Eyes
01234 Watery Eyes
01234 Itchy Eyes
01234 Dark Circles" or "Bags"

GENITOURINARY
01234 Increased Urinary Frequency
01234 Painful Urination

MUSCULOSKELETAL
01234 Joint Aches/Pain
01234 Stiff Joints
01234 Muscle Aches
01234 Stiff Muscles

CARDIOVASCULAR
01234 Irregular Heartbeat
01234 High Blood Pressure

DIGESTIVE
01234 Heartburn/Reflux
01234 Stomach Pain/Cramps
01234 Intestinal Pain/Cramps
01234 Constipation
01234 Diarrhea
01234 Bloating Sensation
01234 Gas (of Any Kind)
01234 Nausea or Vomiting
01234 Painful Elimination

WEIGHT MANAGEMENT
01234 Fluctuating Weight
01234 Food Cravings
01234 Water Retention
01234 Binge Eating or Drinking
01234 Purging (all methods)